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Towards a Biopsychosocial–Spiritual Approach in Health

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Towards a Biopsychosocial–Spiritual
Approach in Health Psychology:
Exploring Theoretical Orientations and
Future Directions
a
Andrew R. Hatala
a
Department of Psychology , University of Saskatchewan ,
Saskatoon , Canada
Published online: 02 Oct 2013.

To cite this article: Andrew R. Hatala (2013) Towards a Biopsychosocial–Spiritual Approach in Health
Psychology: Exploring Theoretical Orientations and Future Directions, Journal of Spirituality in Mental
Health, 15:4, 256-276, DOI: 10.1080/19349637.2013.776448

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Copyright © Taylor & Francis Group, LLC
ISSN: 1934-9637 print/1934-9645 online
DOI: 10.1080/19349637.2013.776448

Towards a Biopsychosocial–Spiritual Approach

in Health Psychology: Exploring Theoretical
Orientations and Future Directions

ANDREW R. HATALA
Downloaded by [University of Saskatchewan Library] at 12:19 03 October 2013

Department of Psychology, University of Saskatchewan, Saskatoon, Canada

The current status of the “biopsychosocial” model in health psy-

chology is contested and arguably exists in a stage of infancy.
Despite original goals, researchers have developed theoretical inte-
grations across biopsychosocial domains only to a limited extent.
In addition, the marginalization of “spirituality” in contempo-
rary biopsychosocial health perspectives is questionable. This article
addresses these issues by providing evidence that supports the inclu-
sion of spirituality within current perspectives while at the same
time discussing implications this inclusion bears on the concept of
health. Overall, a biopsychosocial–spiritual or “holistic” perspective
is advanced for use within health psychology, provided it can be
approached from a multilevel integrative analysis. In the end, some
clinical implications are discussed.

KEYWORDS spirituality, health, biopsychosocial model,

medicine, holistic

Health psychology emerged as a distinct subfield of psychology when the

American Psychological Association’s (APA) Task Force on Health Research
(1976) was commissioned to address concerns over increasing rates of “pre-
ventable” diseases in the United States. During a 50-year span between
1920 and 1970, the prevalence of acute infectious diseases like influenza,
measles, and tuberculosis declined in the United States while what have been
termed “preventable” conditions have substantially increased, including car-
diovascular disease, drug and alcohol abuse, and lung cancer (Matarazzo,

Address correspondence to Andrew R. Hatala, Department of Psychology, University of

Saskatchewan, Arts Building, Room 154, 9 Campus Dr., Saskatoon, SK, S7N 5A5, Canada.
E-mail: andrew.hatala@usask.ca

256
 A Biopsychosocial–Spiritual Model 257

1982; Weiss, 1982). After some success in applying psychological theory

and practice to the promotion of physical health, health psychology for-
mally became Division 38 of the APA in 1978. Today, Division 38 has over
6,000 formal members, one of the largest in the association, and includes
several rigorous research programs, involving: associations among clinically
diagnosable mental disorders and the pathogenesis of physical ailments such
as cardiovascular disease (clinical health psychology; Baum & Poslunsny,
1999; Salomon, Clift, Karlsdottir, & Rottenberg, 2009); effective health inter-
vention, promotion and prevention of disease and illness in schools, work
sites, and “daily living” (public health psychology; Nicassio, Meyerowitz,
& Kerns, 2004; Michie & Abraham, 2004); community health justice and
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social action (community health psychology; Brydon-Miller, 2000; Estacio,

2006; Marks et al., 2005; Murray & Poland, 2006); the identification and
comparison of major etiological agents of illness in a variety of cultures (cul-
tural health psychology; Kazarian & Evans, 2001; Kirmayer, 2004; Shweder,
Much, Mahapatra, & Park, 1997); critiques of mainstream Western approaches
to and understandings of health and illness (critical health psychology;
Chamberlain & Murray 2009; Marks, 2002; Murray, 2004; Prilleltensky &
Prilleltensky, 2003); psychneuroimmunology (Kemeny, 2007); and biological
models linking the social world and physical health (Cacioppo & Berntson,
2007; Hatala, 2012; Miller, Chen, & Cole, 2009; Sarafino, 2006), to name a few.
Underlying this multifarious collection of research within health psychol-
ogy is the position that biological (e.g., genetic predisposition), psychological
or behavioral (e.g., lifestyles, explanatory styles, and health beliefs), and
social factors (e.g., family relationships, socioeconomic status [SES], and
social support) are all implicated in the various stages of pathogenesis and
health etiology. This position is termed the biopsychosocial model (BPS)
and has gradually emerged in consort with related scientific developments
in medicine. During the evolution of medical science from the Renaissance
to the late 19th and early 20th centuries, advances in biology, anatomy,
and physiology eventually crystallized into what is now referred to as a
biomedical model. This perspective yielded a shared set of assumptions (i.e.,
reductionism, naturalism, and mind-body dualism), which relegated illness
and healing primarily to a physiological framework with limited attention to
social, moral or political dimensions (Cohen, McChargue, & Collins , 2003).
It is during this time in the late 1970s that psychiatrist George L. Engel at the
University of Rochester, as well as other clinicians and researchers, began to
enunciate the limitations of biomedicine and a need for a biopsychosocial
perspective.1 Engel (1977) in particular observed a “medical crisis” that he
thought “derives from adherence to a model of disease no longer adequate
for the scientific tasks and social responsibilities of either medicine or psy-
chiatry” (p. 129), and that medical practitioners and researchers “should take
into account the patient, the social context, the physician’s role and the
health care system” (p. 132). Engel’s (1977) articulation of a biopsychosocial
 258 A. R. Hatala

perspective was therefore an important attempt to incorporate the patient’s

psychological experiences and the social or cultural context into a more
comprehensive framework for understanding disease, illness, and health.
Since its introduction, the BPS model has been widely embraced within
medical sciences and health psychology. Presently, the American Psychiatric
Association and the American Board for Psychiatry and Neurology, as well
as several medical schools, psychiatry residencies, and health psychology
graduate programs across North America and Europe officially endorse a
biopsychosocial approach (Ghaemi, 2009; Tavakoli, 2009). Furthermore, sev-
eral health psychologists in particular consider the BPS model to be a guiding
framework for contemporary research and practice (Adler, 2009; Schwartz,
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1982; Sarafino, 2006; Taylor, 1990). In the context of chronic pain, for exam-
ple, Gatchel (2004) and Gatchel, Bo Pang, Peters, Fuchs, and Turk (2007)
argued that the connections among biological changes, psychological status,
and the sociocultural context should all be considered in trying to understand
an individual’s perception of pain. A psychiatric intervention or treatment
approach, Gatchel (2004) further argued, “that focuses on only one of
these core sets of factors will be incomplete” (p. 797). Leventhal, Weinman,
Leventhal, and Phillips (2008) painted a similar picture for addictions, smok-
ing, and alcohol use. To understand these complex “health risk behaviors,”
these authors suggested researchers must investigate one’s cultural, peer, and
family environments; one’s propensity to risk taking and emotional reactiv-
ity; as well as one’s genetic and biological predispositions. Underestimating
any of these three domains will limit a practitioner or researcher’s ability to
predict the likelihood of initiation, rapidity of addiction, and the difficulty of
cessation (Leventhal et al., 2008).
The status of the BPS model, its use and general acceptance within
health psychology, however, is not free from contestation. Several authors
over the years have expressed concerns regarding its limitations, specifically
including: problems with dichotomizing between biology, psychology, and
society (Tavakoli, 2009); problems with its ambiguous status as an actual
“scientific model” (McLaren, 1998, 2009; Stam, 2004); problems of mask-
ing an underlying biomedical approach (Alonso, 2003; Marks et al., 2005;
Stam, 2000); difficulties with the complexity of outlining linkages or prior-
itizing among its subsystems (Ghaemi, 2009; McLaren, 2002; Pilgrim, 2002;
Suls & Rothman, 2004); and a pervasive individualistic focus (Kazarian &
Evans, 2001; MacLachlan, 2000; Marks, 1996; Murray, 2004). In addition, the
marginalized role of spirituality within the BPS model represents another
prominent limitation that is somewhat surprising and unwarranted, not only
because of the surmounting empirical evidence linking health outcomes, for
better or worse, with spiritual or religious factors (Contrada et al., 2004;
Enstrom & Breslow, 2008; Gillum, King, Obisesan, & Koenig, 2008; Idler,
2010; Maltby, 2005; McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000; W.
Miller & Thoresen, 1999; Oman & Thoresen, 2003; Perez et al., 2009; Plante
 A Biopsychosocial–Spiritual Model 259

& Sherman, 2001; Siegel & Schrimshaw, 2002; Sloan, Bagiella, & Powell,
1999; Sloan & Bagiella, 2002), but also because the majority of people from
diverse cultural systems around the world believe in some kind of “higher
power” or faith system (Baetz, Larson, Marcoux, Ruzica, & Bowen, 2002;
Noss, 2003; Pargament, 1997), especially during times of experienced illness
or disease (Baetz et al., 2006; Becker, 1997; Koenig, 2008; Krause, 2006;
Sulmasy, 2002). The absence of a spiritual domain, therefore, represents a
significant limitation of the current BPS model as employed within health
psychology particularly and medical research and practice more generally.
The current article addresses this central limitation by providing evi-
dence that supports the inclusion of spirituality within the current biospy-
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chosocial metatheoretical framework. Thus, it is argued that biopsychosocial–

spiritual or holistic perspectives are useful to guide future research and
practice in health psychology provided that the four domains are approached
from what several developmental psychopathologists and researchers refer
to as a multilevel integrative analysis (Cacioppo, Berntson, Sheridan, &
McClintock, 2000; Cacioppo & Berntson, 2007; Hatala, 2011). This ana-
lytic perspective is inherently multidisciplinary and multiparadigmatic and
assumes equality within all levels of analysis thereby attempting to dismantle
conceptual borders between nature and nurture, biology and psychology, or
science and spirituality.
To meet these ends, this article first examines and reviews con-
temporary literature wherein associations between spirituality and health
are highlighted. Following this the concept of health is reviewed and
critiqued by drawing on previously cited works. Finally, a case for a
biopsychosocial–spiritual model is presented and some clinical implications
are discussed.

RELATIONS BETWEEN SPIRITUALITY AND HEALTH

Common values underlying research and practice in psychology, which often

transmute into naturalism, materialism or a “cult of empiricism” (Nelson &
Slife, 2006; Toulmin, 1992), suggest it unusual to address spirituality within
the realm of disease, illness and health. If, however, we begin to consider
healing not only in light of its original intent, but also in light of surmount-
ing empirical research (McCullough et al., 2000; W. Miller & Thoresen, 1999;
Oman, & Thoresen, 2002), it becomes evident that in fact, there are important
relationships that exist—ones that contemporary health psychology in par-
ticular has all too often neglected. But perhaps what is even more surprising
is the neglect of spirituality within “critical” health psychology (Murray, 2004;
Prilleltensky & Prilleltensky, 2003). In failing to mention religion and spiri-
tuality as a widely available cultural resource for empowerment and health,
Oman and Thoresen (2003) argued that critical health psychology risks “a de
 260 A. R. Hatala

facto collaboration with mainstream psychology in propagating and legiti-

mating cultural disempowerment akin to what Illich long ago termed cultural
iatrogenesis” (p. 224). Thus, important relationships between spirituality and
health may not only exist at an individual level, but amidst broader sociopo-
litical processes such as group identity, community resilience and collective
empowerment as well. Before exploring these relationships in detail and
building a case for biopsychosocial–spiritual (BPS-S) perspectives in health
psychology, we must first ask what spirituality is.
Not surprisingly, defining spirituality is wrought with complications. For
instance, of the eleven studies that Chen and Koenig (2006) analyzed in
their review, the term spirituality was operationalized in 10 different ways.
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Many definitions center on issues of transcendence, where spirituality was

related to a sensed relationship with powers transcending the present con-
text of reality. Others, however, defined spirituality as a particular and distinct
experience, as for example, when one becomes absorbed in the present and
ceases to be preoccupied with the past or the future (Chen & Koenig, 2006).
Furthermore, there are also growing trends to define “individual” spirituality
in contrast to “collective” religion. In these instances spirituality becomes an
individual, subjective, emotional phenomenon; whereas, religion becomes
solely institutional, formal, and doctrinal. Although this distinction is often
held, some researchers contest the bifurcation of religion and spirituality
because most individuals in society do not experience these “inner” and
“outer” aspects as separate (Emmons & Paloutzian, 2003; Hall, Koenig, &
Meador, 2008; Hill & Pargament, 2003; King et al., 2005). Indeed, for our
purposes of exploring spirituality across biopsychosocial domains, which
necessarily engenders both individual and collective experiences, spirituality
is defined as a search for the sacred, or a process through which people
(i.e., individuals and groups) seek to discover, hold on to, and, when nec-
essary, transform whatever they hold sacred in their lives (Pargament, 1997,
2002).
The relations between spirituality and health are attracting researchers
from diverse areas such as medicine, public health, psychology and sociol-
ogy (Idler, 2010). Special issues focusing on spirituality and health research
have appeared, for example, in scientific journals including, the Annals of
Behavioral Medicine (Mills, 2002); the Psychological Bulletin (Worthington,
Kurusu, McCullough, & Sandage, 1996); and the American Journal of
Physical Medicine and Rehabilitation (Underwood-Gordon, Peters, Bijur, &
Fuhrer, 1997). To highlight some key aspects of this research, and for our
current purposes of working towards BPS-S or holistic perspectives, spiritual-
ity’s demonstrated relation to health is explored through biological pathways
(Contrada et al., 2004; Idler et al., 2009); social integration and support (Idler,
2010; Krause, 2006; Oman & Thoresen, 2003); health behaviors (Enstrom &
Breslow, 2008; Gillum et al., 2008; Strawbridge, Shema, Cohen, & Kaplan,
2001); a deeper meaning and purpose within illness experiences (Chen &
 A Biopsychosocial–Spiritual Model 261

Koening, 2006; Kaye & Raghavan, 2002); and negative health effects (Dein
& Littlewood, 2005; Sloan & Bagiella, 2002).

Biological Pathways
Contemporary research on spirituality has observed the many positive
effects on patients’ wellbeing and healing effectiveness. Arndt Büssing,
chair of Medical Theory and Complementary Medicine, University of
Witten/Herdecke in Germany, for example, analyzed the attitudes of patients
with life-threatening or life-altering illnesses and found that when patients
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embraced spiritual themes (i.e., looking for the positive aspects of a chal-
lenging situation, turning to prayer in times of need), they experienced an
increased ability to cope and recover from their illness experiences when
compared to nonspiritual controls (Büssing, Ostermann, & Matthiessen,
2005). Similarly, Nalini Tarakeshwar and collegues (2006) observed that the
use of positive spiritual coping mechanisms, such as belief in the benevolent
purpose of existence, were repeatedly associated with a better overall quality
of life for cancer patients, as well as shorter recovery periods following sur-
gical procedures. Matheis, Tulsky, and Matheis (2006) also showed through
structured interviews and regression analysis that significant positive corre-
lations between measures of self-efficacy and multidimensional measures of
religion and spirituality were apparent in their research among individuals
suffering from spinal cord injuries. Taken together, these studies show how
individuals who embraced spiritual themes, practices or beliefs, displayed
marked increases in healing effectiveness and reduced recovery times after
surgeries.
Previous research also suggests that spiritually inclined individuals may
be more “susceptible” to positive psychological states (i.e., joy, hope, com-
passion), when compared to non-spiritual controls (Koenig et al., 2001;
Pargament, 1997); which, in turn, leads to improved physical health through
enhanced immune and endocrine function (Kiecolt-Glaser & Glaser, 1995),
or reduced allostatic stress load (McEwen, 1998). In a recent study published
in Health Psychology investigating the impact of religious or spiritual striv-
ing on patients recovering from heart surgery, for example, Contrada et al.
(2004) observed that “stronger religious beliefs were associated prospec-
tively with fewer surgical complications and shorter hospital stays” (p. 234),
and that “religiousness predicted surgical recovery with statistical control
of other psychosocial factors” (p. 235). These researchers suggest that reli-
gious beliefs and practices (i.e., prayer, reading scripture, attending worship
services, etc.) may influence cognitive appraisals or coping strategies acti-
vated during pre and postsurgical periods that have modulating effects on
neuroendocrine and immunological activity, which, in turn, bolster recovery
(Contrada et al., 2004). The inverse of these enhanced recovery effects have
 262 A. R. Hatala

also been shown with clinically depressed individuals in delayed healing

of experimentally administered wounds and increased inflammatory activity
via immuno-suppressive alterations (Bosch, Engeland, Cacioppo, & Marucha,
2007; Miller et al., 2009). Spiritual inclinations, therefore, may not only pro-
tect against these ill effects but also add additional modulating effects as well.
In a related manner, Idler et al. (2009) suggested that attendance at spiritual
or religious gatherings act as “exposure variables” or markers for “multidi-
mensional experiences” that activate and integrate sensory, cognitive, and
somatic processes leading to “holistic” spiritual psychosomatic states con-
nected with health outcomes. These holistic experiences, Idler et al. (2009)
observed, typically occur in congregate settings wherein individual effects
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are amplified by synchronized performance and action with others. Thus,

in addition to operating along biological pathways, spirituality also impacts
health through increased social integration, networking or social support.

Social Integration and Support

It is well documented that spiritually inclined individuals have greater access
to and contact with co-spiritualists. Indeed, Putnam (2000) argued, “faith
communities in which people worship together are arguably the single most
important repository of social capital in America” (p. 66). This enhanced
sense of community, in turn, leads to larger and stronger social networks and
greater availability of social support, both of which are robust predictors of
salutary health effects (Idler, 2010). In addition, actual and anticipated social
support is correlated with enhanced recovery from heart surgery (Contrada
et al., 1994) and more adaptive psychological states, such as optimism
(Krause, 2006; Pargament, 1997). Aside from these individual factors, Oman
and Thoresen (2003) question whether spirituality and religion can produce
health benefits at group levels by fostering collective empowerment. These
authors review a large amount of social justice literature and conclude that in
several social movement cases—in North America and around the world—
spirituality has served as an important, if not primary, source of motivation,
guidance and sustenance. When reflecting on recent calls to address health
issues at macro socio-political levels, and thereby align health psychology
with social justice initiatives (Estacio, 2006; Murray & Poland, 2006), Oman
and Thoresen (2003) urged researchers to consider how spirituality and reli-
gion can be used to foster health and empowerment—issues of “power”
in particular being an important agenda proposed in 2003 by Prilleltensky
and Prilleltensky. Previous research suggests, then, that spirituality fosters
health both through individual social support as well as collective community
empowerment—important considerations for health researchers.
Another aspect of spirituality as a source of social integration and sup-
port relies in its ability to engender altruism. Altruism in this context is
generally understood as the human capacity to give one’s self to a goal
 A Biopsychosocial–Spiritual Model 263

or purpose that is greater than one’s self, usually to the service and devotion
of others (Frankl, 1984; Hatala, 2011). Several studies observed that service
to others not only bestows psychological benefit on the practicing individ-
ual, but also, and perhaps more importantly, serves to link the individual
to the broader social world. Rachman, (1979), for instance, suggested that
individuals who helped others by caring for their immediate needs follow-
ing collective traumatic events, were characterized with a “survivor mission”
that was associated with decreased trauma-related mood and anxiety symp-
toms. Furthermore, by turning tragedies into opportunities for activism, these
individuals who adopt a survivor mission where seen to be the most psy-
chologically resilient during the 9/11 attacks on New York as well as more
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adept to find a deeper meaning within the face of adversity (Bonanno, 2006;
Rachman, 1979). Thus, altruistic behaviors that are promoted and often sus-
tained by spiritual practices can foster positive health responses through
psychological states such as hope, a sense of achievement and optimism,
while at the same time serving as a means by which greater connections to
the social world are constructed and nurtured (Hatala, 2011).

Health Behaviors
Another way in which spirituality is associated with health is through the
simultaneous promotion of health-enhancing behaviors and the restriction
of health-impairing behaviors. During the middle of the 20th century, several
epidemiological studies began to document the significantly lower rates of
all-cause mortality, cancer and cardiovascular disease among highly obser-
vant sectarian groups (i.e., Seventh-Day Adventests, Mormons, Amish) when
compared to the general population (Idler, 2010). It was thought that these
groups discouraged smoking, drinking and other negative behaviors as well
as encouraged healthy diets largely on the premise that the body was seen
as an instrument of God’s service. In one classic study, for example, Fuchs
(1974) observed a stark difference between child and adult mortality when
comparing Utah and Nevada. Although many important characteristics are
similar between states, such as income, health care status, climate and popu-
lation density, all-cause mortality in Nevada for males between 40 and 50 was
55% higher than Utah in 1973. Moreover, deaths due to respiratory cancer
and cirrhosis of the liver were 111% higher in Nevada. Fuchs (1974) conclu-
sion was that differing life styles were largely responsible for the variance
since Utah’s population, in contrast to Nevada’s, consists of 70% abstinent,
nonsmoking Mormons who generally live stable productive lives. Similar
findings have been replicated more recently. During a 24-year follow-up
study, for instance, Enstrom and Breslow (2008) found a 45% lower stan-
dardized morality ratio (SMR) for religiously active Mormon females, and
a 55% lower SMR for males, compared to a nationally representative sam-
ple. Similarly, Strawbridge et al. (2001) followed 2,500 adults in California
 264 A. R. Hatala

over 29 years and found that more frequent religious activities (e.g., wor-
ship attendance or daily prayer) were significantly related to the adoption of
positive health behaviors, such as commitment to close social relationships,
regular exercise, and decreased alcohol abuse. Finally, another recent nine
year follow-up study found that in a U.S. national cohort of people over 40
(N = 8,450), all-cause mortality for those who attended religious services
more than weekly was over 30% lower than for those who never attended
(Gillum et al., 2008). Taken together, these studies point to the importance
of spirituality and religion in health promotion, and should be considered
more closely by health psychologists working to improve health status at
individual or community levels.
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Meaning and Purpose in Illness

Spiritual aspirations have long since been understood to provide individuals
with a sense of meaning, hope and purpose in life. Fromm (1964) postu-
lated that spiritual systems potentially satisfy one of the five basic human
needs: a frame of orientation or the need to understand the world and our
place within it.2 In effect, Fromm suggested that humans desire answers to
questions about their life’s purpose, existence after death, and their origin,
which only spiritual systems may appropriately address. When the need for
a frame of orientation is satisfied, hope through adversity is strengthened
and well-being ensues. Similarly, Geertz (1973) and Frankl (1984) suggested
that sacred conceptions of life foster hope as well as make moral sense of
negative experiences (i.e., inequality and injustice), by relating them to a
wider sphere of reality within which they become meaningful. In this way,
psychological resilience springs from the spiritual re-interpretation of one’s
sufferings and the realization that meanings can be found in and constructed
from distressing life events.
Theories about spirituality as a source of meaning and purpose and its
connection to hope, healing, and resilience are increasingly being empiri-
cally investigated. For example, in an extensive meta-analysis investigating
42 samples of some 126,000 people, McCullough et al. (2000) reported
that spiritual inclinations have protective impact on emotional and phys-
ical well-being, can enhance coping for individuals suffering with severe
medical illnesses, and are associated with lower odds of death. In exploring
the relations between spirituality and health, several researchers have also
looked at the importance of spirituality in the midst of and during nega-
tive or disruptive illness experiences. Berger (1990) observed that spirituality
can offer a source of comfort, meaning, and purpose for those experienc-
ing extremely difficult and negative life events. Similarly, Chen and Koenig
(2006) suggested that spirituality serves to integrate seemingly incomprehen-
sible traumas into a “sacred order,” ultimately providing the knowledge that
even traumatizing events have a place within a larger purposeful universe
 A Biopsychosocial–Spiritual Model 265

(p. 372). Kaye and Raghavan (2002) also observed that spirituality relates
to coping and facilitates the process of transcending perceptions of help-
lessness. In a way, perceptions of God being in control of the overall
universe—when an illness has resulted in loss of function and control within
one’s current life—may help, these authors suggested, transcend feelings of
helplessness (Kaye & Raghavan, 2002). Along these lines, Idler et al. (2009)
suggested:

Religious traditions offer frameworks of meaning built on symbols, rituals,

and liturgies for making sense of the painful, threatening, and ultimate
experiences of illness and dying. There is evidence that these frameworks
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are sought out, that they may affect behavior in critical decisions, and that
they may provide benefits in the form of quality of life and emotional
adjustment. (p. 145)

Moreover, spiritual traditions for many centuries have provided the-

ories of human nature and strategies for wellness, whether explicit or
implicit, within dogma, practices, ritual, or sacred texts (Koenig et al., 1998;
McCullough & Larson, 1999; Spilka & Bridges, 1989). Prayer and meditation,
for instance, are often cited as valuable resources that reduce stress while
fostering resilience and healing (Baetz Bowen, Jones, & Koru-Sengul, 2006;
Hatala, 2008, 2011; Shapiro, 2009). Indeed, Baetz et al. (2006) examined the
relation between worship frequency and psychiatric disorders by examin-
ing a diverse Canadian data set from 37,000 individuals from the Canadian
Community Health Survey (CCHS). Overall, these researchers report that
worship frequency or regular devotion was significantly associated with
lower odds of lifetime, current, and past depression, mania, and social
phobia (Baetz et al., 2006). Meditation as a regular spiritual practice, in par-
ticular, is considered to be a primary mechanism by which the previous
positive results occur. In a recent review by Shapiro (2009), meditation has
been associated with positive physiological findings such as stress reduction,
enhanced immune efficiency and positive psychological findings such as
improved memory and intelligence, enhanced creativity, strengthened hope,
advanced attention and concentration, general happiness, increased empa-
thy for others, optimism, self-actualization, self-compassion, moral maturity,
and relapse prevention. Overall, these perspectives suggest that spirituality
can assist individuals to transcend suffering and regain or redefine a sense
of purpose—to find meaning or sense making within the context of illness
experiences.

Negative Health Effects

No study of the relation between spirituality and health would be com-
plete without commenting on spirituality’s potential for ill effects. Miller and
 266 A. R. Hatala

Thoresen (2003) stated that researchers must acknowledge the abuses within
various spiritual or religious systems—just as they would for any major
social institution—and that it is highly probably that certain spiritual prac-
tices or beliefs are related to negative health effects. Indeed, regarding the
ill effects of spirituality, Idler (2010) outlines the tendency for some spir-
itually inclined individuals to make less use of health services, to engage
in fewer positive health behaviors, to interact negatively with other mem-
bers of a congregation, to hold destructive and prejudicial attitudes towards
minority groups, and to struggle with issues of sin or anger, to name a few.
Dein and Littlewood (2005) also remind us of the large sociocultural disrup-
tions that occur during and after “fanatical” mass suicides such as those of
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Jonestown, Waco, or Heaven’s Gate. At a more individual level, Pargament

(1997) observed significant health outcome differences between his three
types of “religious coping orientations,” or the ways that people draw on
religion or spirituality during times of stress. Those individuals with “defer-
ring” orientations, wherein God is expected to somehow resolve all of the
individuals’ problems with little effort required on behalf of the individual,
is consistently shown to have the poorest overall health outcomes, both
psychologically and physically (Pargament, 1997).
In the end, it is clear from these examples that religion and spirituality
can both impair and promote health (Sloan & Bagiella, 2002). Rather than
dismissing these negative health effects, it is suggested that they ultimately
add weight to arguments for the inclusion of spirituality into BPS perspec-
tives insofar as they further document a relation that can and does exist
between spirituality and health. Just as research in health psychology looking
into sociocultural, biological or psychological factors attempts to understand
the situations and contexts that both promote and impede health, so too
examinations into spirituality need to consider its potential ill and positive
effects.

THE CONCEPT OF HEALTH

The concept of health can be defined from many different perspectives

and has important implications for theory, policy, and health promotion.
Biomedical perspectives of health are critiqued because of their reductive,
materialistic, naturalistic, and dichotomistic tendencies, wherein disease is
conceptualized largely as somatic pathology. Health from this perspective,
then, becomes the state in which somatic signs and symptoms are not
present (Engel, 1977). In contemporary literature, the biopsychosocial cri-
tique of these perspectives suggests that health is best understood as a state
of physical, mental and social well-being and not merely the absence of dis-
ease or infirmity (Cohen et al., 2003; Sarafino, 2006). Upon further reflection,
however, and despite good intentions, researchers that do attempt to define
 A Biopsychosocial–Spiritual Model 267

health from BPS perspectives essentially retain many of the assumptions that
underlie and inform biomedicine (Alonso, 2003; Marks et al., 2005; Stam,
2000). Indeed, in reviewing the concept of health and its use within medical
fields, Alonso (2003) suggested that there are essentially no changes in the
conceptualization of health in medical research articles written 20 years ago
and now and that “the spreading of the biopsychosocial model in other con-
texts has not been substantially reflected in the practical areas of medicine”
due to “the still deep-rooted dominance of the biomedical model” (p. 243).
According to Marks et al. (2005), many of the underlying assumptions in
biomedicine—such as moral discourses centered on autonomy and individ-
ual rights—can be observed within contemporary health psychology and
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perspectives of health espoused therein. Although research in medicine and

health psychology pays “political lip service” to biopsychosocial perspectives
(Tavakoli, 2009), the deep rooted cultural contours of biomedicine and its
assumptions of individualism and materialism still pervade as a kind of “folk
model” or “cultural imperative” in both research and practice (Engel, 1977;
Hatala, 2008, 2012).
Moreover, since many underlying Western assumptions of autonomy
and individualism still influence contemporary discourse in health psy-
chology, researchers and practitioners risk a de facto impression of these
assumptions on those with whom they work (Harvey, 2008; Kirmayer, 2007;
Marks et al., 2005). Indeed, Kazarian and Evans (2001) noted that the conse-
quences of a Western bias in the concept of health can manifest as, among
others: the neglect of cultural and linguistic demographics; the lack of con-
sideration of cultural diversity in health service planning, implementation,
and evaluation; the creation of discriminatory health service practices and
disparities in health care access, utilization and outcome; and the marginal-
ization of a diverse array of indigenous health structures, belief systems, and
practices. Many of these issues are clearly exposed in Fadiman’s (1997) nar-
rative wherein several Hmong peoples in the United States are observed to
struggle with contemporary medical approaches—at the core of which lies
differing conceptions of health. Can a holisitc perspective of health address
some of these issues?
In an article that looks at the meaning of healing and a concept of health
from holistic perspectives, Egnew (2005) reminds us that linguistically, the
term to heal means “to make sound or whole” and stems from the root,
haelan, the condition or state of being hal, or whole, while hal also has
the root of “holy,” meaning “spiritually pure” (p. 258). From this perspective,
Egnew (2005) suggested that illness was a threat to the existential integrity
of personhood or identity as conceived within a “whole” relation to physical
(i.e., body functioning), mental (i.e., psychological well-being), social (i.e.,
interpersonal or family relations), or spiritual (i.e., connections with God or
the transcendent) experiences. Health and healing occur, then, by removing
threats to any of these experiences in order to allow for the reinstatement of
 268 A. R. Hatala

the patient’s sense of personhood. Egnew (2005) understood, for example,

that removing a threat might entail curing a specific disease itself, but not
exclusively. Healing may also involve overcoming psychological barriers to
personhood related to the illness experience, from fears of how others will
perceive the illness, to fears of death and dying, or even to fears related to
being a burden on loved ones. Removing a threat may also include address-
ing sociocultural disruptions, such as those related to economic constraints
surrounding an illness. As such, Egnew (2005) proposed that individuals can
transcend suffering when a circumstance is invested with meaning that fos-
ters a reinterpretation of personal wholeness, and concludes by providing a
comprehensive definition of health and healing as “the personal experience
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of the transcendence of suffering” (p. 58).

Adding to these perspectives, Sulmasy (2002) suggested that sickness
was primarily a disruption of “right” relationships. Even at the heart of
biomedical concepts of health and healing, Sulmasy (2002) observed are the
concepts of relations. This is seen, for example, when a physician attempts
to lower one’s blood pressure so that the heart can be in a proper relation-
ship with other vital organs. Sulmasy (2002) continued by suggesting that
illness experiences often disrupt more than relationships within the body,
they “disrupts families, and workplaces and raise questions about one’s
relationship with the transcendent and one’s own self” (p. 26). Health is
therefore a term that refers to a condition of being in right relations in all its
variations:

A human person is a being in relationship—biologically, psychologically,

socially, and transcendentally. Illness disrupts all of the dimensions of
a relationship that constitute the patient as a human person, and there-
fore only a biopsychosocial–spiritual model can provide a foundation for
treating patients holistically. (Sulmasy, 2002, p. 32)

It is important to note, in addition, that from these perspectives one level

of orientation may be “out of balance” yet the overall functioning of the
individual still can remain in a state of health (Sulmasy, 2002). For example,
people can find meaning and purpose within a serious biological condition,
which allows them to lead healthy and productive lives despite disrupted
relations at the biological level (Becker, 1997; Hatala, 2011). Similarly, indi-
viduals struggling with existential questions can report illness experiences in
the absence of any physiological conditions (Kirmayer, 2004). Health, then,
from a more holistic perspective, is more than the absence of disease and
includes social and spiritual factors such as meaning and purpose in life,
ability to contribute to the social well-being of others, and the quality of
intimate personal relationships.
 A Biopsychosocial–Spiritual Model 269

TOWARDS A BIOPSYCHOSOCIAL–SPIRITUAL MODEL

At its inception, there was minimal empirical evidence supporting the impor-
tance of a biopsychosocial approach to health promotion (Engel, 1977). After
several decades of research in health psychology and related health fields,
however, the support for a biopsychosocial perspective is growing. In the
previously reviewed studies, spirituality was seen to enhance, foster or aug-
ment already existing pathways in biopsychosocial domains, such as social
support, behavior, and psychosomatics. In other cases spirituality was seen as
an independent domain that potentially has its own beneficial characteristics
such as a meaning and purpose within illness experiences, the importance
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of ritual and reading from scared texts, or prayer and meditation. Overall,
following a multilevel integrative analysis (Cacioppo et al., 2000; Cacioppo,
& Berntson, 2007; Hatala, 2011)—which takes into account multiple levels of
orientation—it is suggested that health and successful mental health promo-
tion necessarily involves the dynamic interaction of biological, psychological,
social and spiritual domains. Figure 1 extends on Gatchel’s (2004) previous
work by adding a spiritual perspective.

FIGURE 1 A Biopsychosocial–Spiritual Interactive Processes Involved in Health and Illness.

Adapted from Gatchel, R. J. (2004). Comorbidity of chronic mental and physical health conditions:
The biopsychosocial perspective. American Psychologist, 59, 792–805. Copyright 2004 by the American
Psychological Association.
 270 A. R. Hatala

In terms of clinical implications, this review suggests that future health

intervention programs and research should focus on the holistic interaction
between these four domains rather than addressing them as separate aspects
of the individual or environment. The continual maturing of the BPS model
may also depend upon the extent to which any and all of these levels (genet-
ics, biology, psychology, sociality, ecology, and spirituality) are involved and
overlap within even the simplest of interventions (Kirmayer, 2004). Future
research could examine the effectiveness of these claims in the context of
clinical practice, explore the concept of health from these perspectives, and
how these perspectives may influence current trends in the promotion of
health, mental health and well-being.
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NOTES
1. Ghaemi (2009) observed that the biopsychosocial concept was actually coined by Roy Grinker
in the 1950s. Other medical researchers such as Knowles (1977), Leigh and Reiser (1977), and Lipowski
(1977) also supported and outlined a biopsychosocial position. Engel (1977), however, is still largely
responsible for its popularization in medical science and health psychology.
2. Erich Fromm (1964) postulated five basic human needs: (a) relatedness, relationships with oth-
ers, care, respect, knowledge; (b) transcendence, creativity, developing a loving and interesting life; (c)
rootedness, a feeling of belonging; (d) sense of identity, to see ourselves as a unique person and part of
a social group; and (e) a frame of orientation, the need to understand the world and our place in it.

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